1. Caesarean myomectomy was historically discouraged due to risks of hemorrhage, difficulty securing hemostasis, and potential need for hysterectomy or blood transfusion. 2. However, recent evidence suggests that caesarean myomectomy can be safely performed by an experienced surgeon, even in cases of large myomas, without increasing intra- or post-operative complications when proper techniques are used. 3. Future fertility and subsequent pregnancy outcomes appear unaffected by caesarean myomectomy according to current evidence.

1. Prof. Rokeya Beguum
Prof and Advisor
Dept of OBG/ GYNAE
USTC
Director Surgiscope fertility centre
Chittagong, Bangladesh
Tackling of Myoma
During Caesarean Section

2. World wide caesarean sections are on rise
1. It is common benign tumour
2. Prevalence is increasing due
- Delay in child bearing
- Better imaging technique
0.37-12%
There is no clear guideline regarding tackling these myoma during
caesarean section.
There is dilemma and debate.

3. Effect of pregnancy on myoma
60-70% fibroid do not have any change in size
20-25% increase in size mainly occurs in first and early
second trimester
In puerperium
Majority of fibroids shows on changes
5-10% reduce in size

4. Diagnosis
Antenatally
Accidental
Known

5. Sir Victor Bonney
The pioneer in myomectomy
He wrote:
“It is tempting for the adventurous and sympathetic surgeon to
condense the operation of caesarean section and myomectomy into one
undertaking and so to save his patient the ordeal of a second admission to
hospital. This kindly and misguided policy we heartily deprecate.”

6. Caesarean myomectomy have the life threatening complications-
- Massive blood loss
- Peripartum hysterectomy
- Blood transfusion
- Admission in ICU
- Adhesion formation
- Scar integrity in subsequent pregnancy

7. Doing Nothing is easy
that’s why many people
do it

8. What to do
1. Leave it
2. Leave it with uterine
artery ligation (UAL)

9. 1.Leave it
Caesarean myomectomy was practically absent from the-
1. Obstetric literature until the last decade.
2. Myomectomy discouraged in all the leading text book despite the
lack of any direct evidence supporting the approach.
Reasons
 Hemorrhage
 Difficulty in securing haemostasis
 Need for blood transfusion
 Hysterectomy
 Operative morbidity

10. What happens if leave it . This is not safe
1. PPH
2. Inversion of uterus
3. Spontaneous expulsion
4. Intramyometrial haemorrhage
- Involution of uterus compresses the venous drainage
- Blood sequestration into the tumour
- Hypovolaemia and shock
5. Sepsis

11. 2. Leave it with UAL
Uterine artery ligation promising method for treating pregnant
women with myoma.
- Reduce blood loos
- Reduce blood supply
- Minimize necessity for future surgery
• Lactation
• Puerperium
• Reduce size

12. Removal/Caesarean myomectomy
Reasons:
- Avoid repeat surgery
- Relieves symptom
- Reduce postpartum complications
- Save cost and time

13. Caesarean myomectomy after baby delivery

14. Type
Selective
Routine
- All myoma
- Particular

15. Removal of pedunculated fibroid only.
Removal of pedunculated anterior subserous lower uterine
segment fibroid.
Removal of all anterior uterine fibroids without post, cervical
and cornual
Removal of all fibroid
Size more than 5 cm
Selective removal of fibroids

16. Main principles of myomectomy during caesereen
Experience and skill person
Well equipped tertiary institution
Better aneasthesia and available blood
Full consent and counselling
High Hb level
Size and site of myoma
Good assistant

17. Procedure
1. Delivery of baby before attempting myomectomy
Rare situation
Myoma in lower segment in the incision line
- Myomectomy first then C/S
- Classical C/S or upper segment incision

18. Procedure
2. Closing the uterine wound first then myomectomy.
Endometrial myomectomy
Submucous
Posterior wall myoma
Intramural myoma
Endometrial myomectomy causes endometrial synaechiae due to endometrial suture.
Evidence
Rapid involution of uterus diminishes the dead space and suture sites therefore
endometrial scarring is minimized automatically and no chance of Asherman,s syndrome.
Less chance of intraperitoneal adhesion

19. Endometrial myomectomy

20. Serosal myomectomy
Adhesion
Reduce future fertility
Minimized by -
Single incision
Smaller incision
Apposition
Base ball suture
Antiadhesive agent

21. 3. Myomectomy by sharp dissection.
Enucluation of myoma easy because of loose tissue
More muscle damage during pregnancy
Less healing due to contraction of uterine muscle
during puerperium
Weak scar
Rupture uterus
Evidence is scanty

22. Dead space obliteration by
meticulous suturing in
three layers.

23. 4. Excessive bleeding ultimately peripartum hysterectomy.
Haemorrhage can be reduce by -
Uterotonic agent
Step wise devascularisation
Local vasoconstrictor
Vasopressin
Noradrenaline
- Jungle juice

24. Tourniquets
Myomectomy Clamp
Liberal use of diathermy
Tranexamic acid
Gelatin matrix
Kept intraperitoneal drain insitu
Multiple myoma in multiparous – Hysterectomy
Prophylactic antibiotics
Analgesics
Postoperative period stormy

25. The recurrence of uterine fibroids
It is likely to be higher than after
myomectomy in the non pregnant state.

26. Future fertility
The future fertility and/or subsequent
pregnancy outcome was unaffected by
caesarean myomectomy.

27. Key to success
Careful case section
Detail counselling and consent
Well equipped set
Blood transfusion facilities
Skilled surgeon
Technical secret
Build up antenatal HB%
Incision on contracted uterus
Control blood loss.

28. Consensus
• Caesarean myomectomy can be safely done by experience surgeon
even in large myoma with no increase in intra and post operative
complications. (Evidence level IIa)
• Future fertility and subsequent pregnancy outcome was
unaffected by caesarean myomectomy. (Evidence level III)
• Should be done by experienced obstetrician preferably in
superficial subserosal fibroid.

29. Is not absolutely contraindicated
Decision depends on
Location, size, number
Preoperative counselling and consent
Individualized
Management in tertiary set up
Summary

30. It is the time to change as
Charlie Chaplin rightly said
“Nothing is permanent in this
wicked world – not even our troubles”

31. Caesarean myomectomy no longer a fer
fetched job in modern obstetrics
We have to prepare.